Wednesday, January 28, 2009

I'm a physician. I deserve nice things.

I had never heard about this blog until my Google alert sent me the link under the keyword “industry-sponsored CME.”

I encourage you to read the entire article, which is well argued, and does a great job of being indignant without sounding mean or strident, a skill in which I could use some tutoring.

One excerpt:

Oddly--well, actually, not oddly at all--the real argument running beneath these rationalizations is virtually never spoken of. It's pretty simple, actually, and Doctor Rubin, despite his immense respect and affection for the vast majority of his colleagues, has heard that silent-yet-powerful argument since his early days in med school. The "argument," such as it is, is this: I am a physician and that entitles me to nice things. Trinkets, such as free hors d'oeuvres at the cocktail hour following the day's professional meetings, fancy dinners on the tab of the local drug rep, tax-deductible trips to "educational conferences" in the Bahamas--all this is part of the trappings of the lifestyle of a doc. Such is the mentality that resists seeing the obvious conflict-of-interest in industry sponsorship of CME; the defense of the indefensible rests on an emotional response, not a rational one. Until that mentality, that sense of entitlement changes, you can count on organized physician opposition to the meek suggestion that, you know, perhaps we might want to reconsider our relationship with groups whose job it is to make money, given that our job is theoretically to heal patients.

17 comments:

Doctors/and highly-educated professionals of all stripes seem to acquire this attitude in the process of being educated. Until the system stops teaching y'all that you are a different and special class of citizen, I don't think anything will change.

I have several doctors in my family, and I don't get along particularly well with any of them...they all have this attitude...

of course, one of my best friends is a doc too and you couldn't find a humbler man...but the stereotype seems to be an accurate generalization and it really hurts how well one can perform their job in numerous ways...not just simple conflict of interest issues.

I still await evidence of any harm to a patient from advertising. If you provide no evidence, then the complaints are conclusory and expressions of bias.

Dan, do you plan to watch the Superbowl? This expensive show will be for free because of industry advertising. I love Bud Light commercials. Bud Light gives be bad headaches. Will I ever drink Bud Light? Never.

I assume you will not be watching the Superbowl because the ads would unduly influence your future purchases. As a doctor, you are so easily influenced, you should not be allowed to watch the Superbowl, a free but expensive, industry sponsored event.

I would take the risk to go further and say it is moreso our older colleagues who push this attitude to the pathetic degree it has deteriorated to now. They lived on the high hog for twenty or more-some years into the latter 1980's and then resented/outraged they could not get away billing $250 an hour for therapy/evaluations any longer. So, suck on the teet of big pharma, who would pay out the losses in income by insurers, as long as one prescribed their meds.

Think about it, look at who bitches the most about this issue being exposed. They are a good part of why this played out this way, and they have no ego strength to acknowledge it.

By the way, SC, this Super Bowl argument is a retread from last year, and it is not equivalent to the issue of this blog. And, what is this "As a doctor, you are so easily influenced"? If directed to Dr Carlat, do you really read the posts?

Re Superbowl: As consumers we face no conflict of interest by willing exposure to product promotion. But MDs are in a different position in our professional role. We have a fiduciary responsibility to provide unbiased advice to patients, and a corollary responsibility not to invite bias into our clinical decision-making. A professional beer judge would face similar constraints about viewing Superbowl ads just before officially comparing Bud Light to its competitors.

Quoth Dr. Rubin, "As of 2001, drug companies paid over sixty percent of the costs of CME, and it does not appear the number is dramatically declining".

Absolutely, and you get what you pay for. Not only are we not entitled to trinkets because we're docs, we're not entitled to free CME. You want unbiased CME, pay for it. Go take a course, or subscribe to Danny's excellent newsletter.

(Although - maybe there's a bit of conflict of interest in having a blog and a crusade that drives people to buy your product, now that I think about it.)

Steve: After watching a commercial you have a fiduciary duty to your family to not waste money on every advertised product. You have a fiduciary duty to not buy everything after being weak and tempted, because family has no need, and because generic product alternatives are cheap and effective. Dan is saying docs are so weak, they lose it after advertising and just buy everything advertised.

If ads are pea shooters, patient outcomes are atom bombs. And docs are driven by pride in their craft and by their public reputations. The idea that ads, trinkets and dinners affect prescribing outside of providing new information is extraordinary, requiring lots of evidence. There is none.

SC: Yes, there are personal (family) fiduciary responsibilities too. These are more vague and debatable, less codified, than a doctor's professional duty to patients. For a more detailed ethical discussion, see my latest blog post:

http://www.stevenreidbordmd.com/2009/01/no-free-lunch.html

As for evidence, there have been a number of empirical studies documenting non-rational prescribing following exposure to pharma pitches. In my view, the burden is on those who claim that ads, trinkets, and dinners do NOT influence prescribing, since that is clearly their intent.

It's always seemed to me that a great sense of insecurity and needing to "demand respect" motivates many people to pursue advanced degrees. Not all, certainly, but many. And these types, less interested in noble goals than their own aggrandizement, are more vulnerable to seeking perks.

As for this, Daniel: "does a great job of being indignant without sounding mean or strident, a skill in which I could use some tutoring."

Steven: You have native lawyer talent. You would do well in law school, and would enjoy it.

Here is a little preview. Here in the USA, we have legal remedies after a harm is shown. We do not pre-chill speech. Clinical judgment second guessed after an adverse result reflect outcome bias, and nothing more.

As to Dr. Reidbord's statement that "there have been a number of empirical studies documenting non-rational prescribing following exposure to pharma pitches," I've gotta believe he's right. Just a few hours ago, I received a call from a lawyer friend who is in the middle of a trial and all of a sudden his client is drooling on himself because his psych prescribed an atypical to help him (the defendant) sleep and what should he (my lawyer friend) do? Not one to second-guess the man's physician, I rattled off a number of hypnotics and dosages that might assist his client sleep w/out the side effects. Grant it, I am not familiar with the man's concomitant illnesses, if any, but this atypical -- though a great drug for a number of disease states -- is a rather irresponsible thing to prescribe to a person who can't sleep because he's in the middle of a trial wherein the S.E.C. will take his life away should he lose. Who would write a script for this drug as a first-line hypnotic other than a non-rational prescriber? I don't doubt for a second that many of you can construct an elegant defense for this psychiatrist, as I can (maybe), but I couldn't help but think when I hung up the phone, "that's pretty weird man."

"I still await evidence of any harm to a patient from advertising. If you provide no evidence, then the complaints are conclusory and expressions of bias."

You are saying that prescribing medications based on pharmaceutical company propaganda doesn't harm patients? That the billions of dollars being spent on medications that don't work particularly well, just because pharmaceutical companies don't want cheaper medications to be used doesn't harm patients? That harms everybody, patients included.